u

Please Fill & Print Out the following questionnaire. (Print BEFORE clicking the Submit Button!)

If you have trouble printing or submitting you can download the questionnaire HERE to print out & bring in.

Cosmetic Interest Questionnaire

Patient Name:  

 Date:
Email:  

Phone:

 Health issues and procedures or products of interest to you.
(Please check all that apply). 

BOTOX® Cosmetic (Botulinum Toxin Type A) Skin Care Advice
AHA and Glycolic Peels  Skin Care Products
Collagen Therapy   Liver Spots/Age Spots
Skin Rejuvenation Sunscreen Advice
Avage™, Retin-A or Renova Removing Leg Veins
Microdermabrasion  Facials
Acne Hair Removal
Chemical Peels

Spider Vein Treatments
Laser Treatments Removing Facial Veins
Other  
     
Have you ever seen a dermatologist or other physician for your skin? Yes No
If yes, when and why?

Have you previously had:
Chemical Peel?  Yes No

Type of Peel:

Date:

Laser Resurfacing, Dermabrasion, or Microdermabrasion? Yes No Type/Depth (if known)

Date:
Facial Surgery? Yes No

Procedure

Date:

Have you done any aggressive exfoliation to your skin in the last 2 weeks? Yes No
  If yes, explain:
What skin care products do you use frequently?
Are you taking Accutane®? Yes No

If yes, what dosage and frequency?
Have you ever taken Accutane®? Yes No

If yes, last taken on?

Date:
     
What topical medications do you use or have you used?

Retin-A®

Hydroquinone
     
Have you ever used topical fluorouracil preparation on your skin? Yes No
  If yes, when?   On what area of your body?
Other: (This includes topical antibiotics, OTC acne remedies, Hydroquinone, etc.)
   
Please list any oral medications you currently take: (This includes hormones, birth control pills, antibiotics, tranquilizers, anti-depressants, diuretics, etc.)

HYPERSENSITIVITY AND SKIN FRAGILITY:

Have you ever had a skin allergy or sensitivity (rash, irritation, peeling swelling, hives, etc.) Yes No

Allergic Reaction to:
Cosmetics Fabrics

Other: (i.e. latex, etc.)
 

Do you have any known allergies to anything? Yes No
  If yes, please list all allergies: (this includes medications, aspirin, food, etc
 
     

Do you “flush” or “appear reddened” easily when you eat spicy food, drink alcohol, get angry, go into the sun, etc.? 

 Yes No

FREE RADICAL EXPOSURE

Do you smoke? Yes No How much?

Do you consume alcohol? 

Yes No How much?
Do you have a healthy diet? Yes No List any dietary concerns:
Do you exercise? Yes No How much?
Do you take vitamins? Yes No Multi-Vitamins:
      Antioxidants:

FOR WOMEN ONLY

Do you have regular periods? Yes No
Are you going through menopause?    Yes No
Are you pregnant or lactating?  Yes No
If yes, during pregnancy did you ever experience hyperpigmentation or a pregnancy mask? Yes No
Are you trying to become pregnant? Yes No

PIGMENTATION (Fitzpatrick Scale):

How do you tan?
  I Burn II Usually Burn III Sometimes Burn
  IV Rarely Burn V Never Burn-“Brown” VI Never Burn-“Black”
         
Pigmentation: Even Uneven Birthmark Pregnancy Mask

FACIAL WRINKLES:        

  Deep wrinkles Crow’s feet Fine lines
       
Have you been treated with?

Botox®

 Collagen

If yes, date of last treatment:
       

SKIN TYPE:  

Does your skin ever flake and feel tight and dry? Frequently Occasionally Very Rarely
Is your skin ever dry a few hours after cleansing? Frequently Occasionally Very Rarely
How often do you experience blackheads or blemishing? Frequently Occasionally Very Rarely
How noticeable are your pores? Very T-zone Not Very
       

HOW DO YOU WANT TO IMPROVE YOUR SKIN? 

1.
2.

Back to Top